Enclosed is Form 1095-A: An Important Tax Document You Will Need To File Your 2015 Federal Income Tax Return

Dear HealthSource RI Customer:

Earlier this month we asked you to watch the mail for an important tax document. Enclosed with this letter, please find Form 1095-A: Marketplace Statement. We are sending you this document because you or a family member enrolled in health insurance through HealthSource RI for all or part of 2015.

If you received advance premium tax credits to lower your monthly premium payment, you must file a federal tax return and complete Form 8962: Premium Tax Credit to calculate the actual amount of total tax credits you should have received in 2015. (Form 8962 is available from the IRS at www.irs.gov/aca or from your tax preparer.) Form 1095-A provides the information you will need to fill out Form 8962, such as who in your family had health insurance each month in 2015, how much you paid for insurance each month, and the amount of tax credit that was sent to your health plan each month to help pay your monthly premium.

The total Advance Premium Tax Credits most customers received during the year will not match their final Premium Tax Credit calculated on their Form 8962.

You may remember that the amount of advance tax credit you received to help you pay your monthly health insurance premium was based on your estimated income and family information for 2015. The final determination on your eligibility for tax credits is made when you file your tax return and your actual income is known for certain. If you received too little tax credit over the course of 2015, you may get money back when you file your taxes. If you received too much tax credit, you may need to pay back the difference, either in the form of a reduced refund or an amount due when you file your taxes. When you complete Form 8962, you will learn if you need to pay back some of the tax credit you received or if you will receive more money when you get your refund.

It is expected that the tax credit amount for many customers will need to be adjusted on their return when they file their taxes because the information on their forms will not match. This may be due to unreported changes in income or family circumstances during the year, providing incorrect information when enrolling, or due to errors in calculations or errors made by HealthSource RI when these changes were reported.

If you need help completing your federal tax return, free assistance is available to those filing with low and moderate household incomes ($53,000 or less per year) through the Volunteer Income Tax Assistance program sponsored by the IRS. To find a location near you, call 2-1-1, visit http://www.irs.gov/Individuals/Free-Tax-Return-Preparation-for-You-by-Volunteers or go to the ‘Help during Tax Season’ section of HealthSourceRI.com for a list of locations opening after January 30th.

Thank you for being a customer of HealthSource RI. We look forward to serving you in 2016.

Sincerely,

The HealthSource RI Team (over) Form 1095-A Frequently Asked Questions

What if my Form 1095-A has incorrect information? avoid this happening again next year. You can call us at Visit HealthSourceRI.com/get-help-tax-season/ or 1-855-408-1344 to learn more. call us at 1-855-408-1344. It is important to understand that your Form 1095-A cannot be corrected over the What if I received tax credits but don’t file a return? telephone. You will need to tell us why you think the Healthsource RI reports all tax credits to the IRS. Failure form is incorrect. Reviewing your Form 1095-A may to file is a very serious matter and may impact your require us to conduct research on your account history eligibility to receive tax credit in the following year. and this may take up to 30 days to complete. If we cannot complete our review within this timeframe, we Why did I also receive Form 1095-B? will notify you. Only HealthSource RI can review and If you received Form 1095-B, healthcare coverage was amend your Form 1095-A. also provided for one or more family members in the program. (If a family member has Medicaid What if I didn’t receive advance tax credits? coverage, you received an “anchor card” in addition to a If you enrolled in coverage through HealthSource RI in health plan card from Neighborhood Health Plan or 2015 but did not receive advance premium tax credits, UnitedHealthcare). There are no tax credits in you may complete Form 8962 to determine if you are Medicaid; Form 1095-B simply helps you or your tax eligible to receive a premium tax credit. The law allows preparer to report who had health insurance coverage you to take the tax credit in advance or when you file during the year (this information is needed to complete your federal taxes–it’s your choice. You can also choose your federal tax return). to take part of the credit in advance and receive any balance when you file your taxes. How to Get Help: IRS and Tax Preparers

The IRS has developed very helpful information on how What if I received a larger amount of tax credits than I the (ACA) may impact your 2015 should have, but I can’t pay it back? federal tax return. Please visit www.irs.gov/aca for an If you received too much in advance tax credit, the law extensive list of questions and answers and other limits the maximum payback for most people. The resources you may find useful. You can also call the IRS amount you must pay back to the IRS is based on your at 1-800-829-1040. final income—the lower your income, the lower the amount of the payback. When you complete Form Should I keep my Form 1095-A after I file my taxes? 8962, you will find out if a maximum payback amount It is important to keep your Form 1095-A for your applies to you. If you are entitled to a larger tax credit records. If you lose Form 1095-A, a copy can be than you received in advance, you will receive the full downloaded from the ‘Notices’ tab of your online amount as part of your refund. account with HealthSource RI. A copy of the Form

1095-A has been sent to the IRS as required by law. The maximum payback amounts help protect you from incorrect estimates, changing circumstances and mistakes. If you do find that you owe money this year, HealthSource RI can work with you now to help

For more information visit HealthSourceRI.com/get-help-tax-season/or call us at 1-855-408-1344. VOID OMB No. 1545-2232 Form 1095-A Health Insurance Marketplace Statement

▶ Department of the Treasury Information about Form 1095-A and its separate instructions CORRECTED 2015 is at www.irs.gov/form1095a. Part I Recipient Information

1 Marketplace identifier 2 Marketplace-assigned policy number 3 Policy issuer's name

4 Recipient's name 5 Recipient's SSN 6 Recipient's date of birth

7 Recipient's spouse's name 8 Recipient's spouse's SSN 9 Recipient's spouse's date of birth

10 Policy start date 11 Policy termination date 12 Street address (including apartment no.)

13 City or town 14 State or province 15 Country and ZIP or foreign postal code

Part II Covered Individuals

A. Covered individual name B. Covered individual SSN C. Covered individual D. Coverage start date E. Coverage termination date date of birth

16

17

18

19

20 Part III Coverage Information

Month A. Monthly enrollment premiums B. Monthly second lowest cost silver C. Monthly advance payment of plan (SLCSP) premium premium tax credit

21 January

22 February

23 March

24 April

25 May

26 June

27 July

28 August

29 September

30 October

31 November

32 December

33 Annual Totals For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60703Q Form 1095-A (2015) Form 1095-A (2015) Page 2

If advance credit payments are made, only the individuals for Instructions for Recipient whom you attested the intention to claim a personal exemption You received this Form 1095-A because you or a family member deduction (yourself, spouse, and dependents) to the Marketplace at enrolled in health insurance coverage through the Health Insurance enrollment will be listed on Form 1095-A. If you attested to the Marketplace. This Form 1095-A provides information you need to Marketplace at enrollment that one or more of the individuals who complete Form 8962, Premium Tax Credit (PTC). You must enrolled in the plan aren't individuals for whom you intend to claim a complete Form 8962 and file it with your tax return if any personal exemption deduction on your tax return, those individuals amount other than zero is shown in Part III, Column C, of this won't be listed on your Form 1095-A. For example, if you indicated Form 1095-A (meaning that you received premium assistance to the Marketplace at enrollment that an individual enrolling in the through advance credit payments) or if you want to take the policy is your adult child for whom you won't claim a personal premium tax credit. The filing requirement applies whether or not exemption deduction, that child will receive a separate Form 1095-A you're otherwise required to file a tax return. The Marketplace has and won't be listed in Part II on your Form 1095-A. also reported the information on this form to the IRS. If you or your If advance credit payments weren't made and you didn't identify family members enrolled at the Marketplace in more than one at enrollment the individuals for whom you intended to claim a qualified health plan policy, you will receive a Form 1095-A for each personal exemption deduction, Form 1095-A will list all enrolled policy. Check the information on this form carefully. Please contact individuals in Part II on your Form 1095-A. your Marketplace if you have questions concerning its accuracy. If Part II also tells the IRS the months that the individuals identified you or your family members were enrolled in a Marketplace are covered by health insurance and therefore have satisfied the catastrophic health plan or separate dental policy, you aren't individual shared responsibility provision. entitled to take a premium tax credit for this coverage when you file your return, even if you received a Form 1095-A for this coverage. If there are more than 5 individuals covered by a policy, you will For additional information related to Form 1095-A, go to receive one or more additional Forms 1095-A that continue Part II. www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Health- Part III. Coverage Information, lines 21–33. Part III reports Insurance-Marketplace-Statements. information about your insurance coverage that you will need to VOID box. If the "VOID" box is checked at the top of the form, you complete Form 8962 to reconcile advance credit payments or to previously received a Form 1095-A for the policy described in Part I. take the premium tax credit when you file your return. That Form 1095-A was sent in error. You shouldn't have received a Column A. This column is the monthly premiums for the plan in Form 1095-A for this policy. Don't use the information on this or the which you or family members were enrolled, including premiums previously received Form 1095-A to figure your premium tax credit that you paid and premiums that were paid through advance on Form 8962. payments of the premium tax credit. If you or a family member CORRECTED box. If the "CORRECTED" box is checked at the top enrolled in a separate dental plan with pediatric benefits, this of the form, use the information on this Form 1095-A to figure the column includes the portion of the dental plan premiums for the premium tax credit and reconcile any advance credit payments on pediatric benefits. If your plan covered benefits that aren't essential Form 8962. Don't use the information on the original Form 1095-A health benefits, such as adult dental or vision benefits, the amount you received for this policy. in this column will be reduced by the premiums for the non- essential benefits. If the policy was terminated by your insurance Part I. Recipient Information, lines 1–15. Part I reports information company due to nonpayment of premiums for one or more months, about you, the insurance company that issued your policy, and the then a -0- will appear in this column for these months regardless of Marketplace where you enrolled in the coverage. whether advance credit payments were made for these months. Line 1. This line identifies the state where you enrolled in coverage Column B. This column is the monthly premium for the second through the Marketplace. lowest cost silver plan (SLCSP) that the Marketplace has Line 2. This line is the policy number assigned by the Marketplace determined applies to members of your family enrolled in the to identify the policy in which you enrolled. If you are completing coverage. The applicable SLCSP premium is used to compute your Part IV of Form 8962, enter this number on line 30, 31, 32, or 33, monthly advance credit payments and the premium tax credit you box a. take on your return. See the Instructions for Form 8962, Part II, on Line 3. This is the name of the insurance company that issued your how to use the information in this column or how to complete Form policy. 8962 if there is no information entered. If the policy was terminated by your insurance company due to nonpayment of premiums for Line 4. You are the recipient because you are the person the one or more months, then a -0- will appear in this column for the Marketplace identified at enrollment who is expected to file a tax months, regardless of whether advance credit payments were made return and who, if qualified, would take the premium tax credit for for these months. the year of coverage. Column C. This column is the monthly amount of advance credit Line 5. This is your social security number. For your protection, this payments that were made to your insurance company on your form may show only the last four digits. However, the Marketplace behalf to pay for all or part of the premiums for your coverage. If this has reported your complete social security number to the IRS. is the only column in Part III that is filled in with an amount other Line 6. A date of birth will be entered if there is no social security than zero for a month, it means your policy was terminated by your number on line 5. insurance company due to nonpayment of premiums, and you Lines 7, 8, and 9. Information about your spouse will be entered aren't entitled to take the premium tax credit for that month when only if advance credit payments were made for your coverage. The you file your tax return. You still must reconcile the entire advance date of birth will be entered on line 9 only if line 8 is blank. payment that was paid on your behalf for that month using Form Lines 10 and 11. These are the starting and ending dates of the 8962. No information will be entered in this column if no advance policy. credit payments were made. Lines 12 through 15. Your address is entered on these lines. Lines 21–33. The Marketplace will report the amounts in columns A, B, and C on lines 21–32 for each month and enter the totals on line Part II. Covered Individuals, lines 16–20. Part II reports 33. Use this information to complete Form 8962, line 11 or lines information about each individual who is covered under your policy. 12–23. This information includes the name, social security number, date of birth, and the starting and ending dates of coverage for each covered individual. For each line, a date of birth is reported in column C only if an SSN isn't entered in column B.